Five years ago the Illinois Department on Aging established parameters for consumer-centered home care and adult day services. At the same time, the Community Care Program Advisory Council recommended creating an ethics mechanism to enrich the provision of such care. The Park Ridge Center was invited to join this effort.

With generous funding from the Retirement Research Foundation, Center staff interviewed case managers, supervisors, and frontline workers to identify the troubling issues they faced daily. We also interviewed clients to find what they wanted from caregivers. Although we learned much, so many of the problems seemed intractable. We were, after all, talking about caring for people with fragile physical and or mental conditions in a public system with limited caregiving resources. This system also relied heavily on family members, most often women, who face multiple demands on their time.

Recognizing all these factors, the project working group developed an ethics training program. It uses a train-the-trainer model to educate frontline workers who have the most hands-on contact with elderly clients. Support materials are sufficiently rich to deepen and broaden the trainer's knowledge about ethics. We developed two packages, one for home care and one for adult day services. The home care program includes a video portraying the case narratives that are in the training program. A separate handbook provides further support materials.

During a test of the program's usefulness, frontline workers were extraordinarily receptive. They brought insights from their own experiences to the case discussions and became a living testimony to the power of knowledge grounded in experience. The program was then revised and is currently being finalized.

The training program acknowledges that home and community-based care matters a great deal to elders and their families and that for many of those families the frontline workers are the key to its success. Thirty to fifty million older Americans cannot remain in their own homes—where most want to be—without assistance in the basic tasks of living. Home care involves a complex set of intersecting, and often unequal, relationships in an emotionally charged environment where physical and mental loss and approaching death are ever-present realities. The home, a place that vitally supports the older person's efforts to protect self-identity and moral worth, is also the scene of a moral drama. In this drama, all involved work to create an environment where givers and receivers of care can flourish against heavy odds, and where the right amount of helpfulness can be given in just the right way.

The training program has an expansive view of the moral life and ethics. It builds upon the central themes of attentiveness and responsiveness, and the particularities of caring for this person in ways that enhance dignity and preserve self-respect. Built around case narratives, the training program encourages critical reflection about values and choices.

In one narrative, for example, the client gives every indication that she wants to die, raising questions for caregivers: What do the client's behaviors mean? What values are in conflict? What can the worker do and how can she approach her very busy supervisor?

Another narrative presents what seems to be an abusive relationship between a client and her son. This case narrative asks workers to think about questions of safety when protection might mean interrupting a relationship that means a great deal to the client, especially in situations where society has few alternatives to offer the older person.

In one day-services case, two clients are flirting, troubling some clients and staff at the site: Where does one draw the line between acceptable and unacceptable behaviors, and on what grounds? How can the day-services center preserve an atmosphere of emotional security?

The training program's goals are to: familiarize workers with the moral importance of their work; prepare caregivers to engage in caring practices; increase the knowledge of caregivers about the ethical aspects of everyday caregiving; and develop skills to prevent problems or recognize and resolve them. We anticipate that the completed resources will be available this fall.